CDIFF Flashcards
definition of acute infectious diarrhea
- increase freq of defecation lasting <14d
- diarrhea >= loose or liquid stools or more freq than personal normal
- cause by 1 or more microorganism
bacterial causes of acute infectious diarrhea
- campylobacter jejuni
- salmonella typhio
- shigella spp.
- eshcerichia coli
- vibrio cholera
- clostridioides difficile
protozoal causes of acute infectious diarrhea
- giardia intestinalis
- entamoeba histolytica
- cryptosporidium parvum
viral causes of acute infectious diarrhea
- notovirus
- rotavirus
- adenovirus
diagnosis for acute infectious diarrhea
- fecal occult blood, ova and parasite
- stool cultures
- polymerase chain reaction PCR
who are diagnostic test usually for
patients with:
- severe illness
- persistent fever
- bloody stools
- immunosuppression
- unresponsive to tx
prevention of acute infectious diarrhea
- good hand food hygiene
2. vaccinations (eg. cholera, typhoid, rotavirus)
non pharmacological tx for acute infectious diarrhea
- early re-feeding as tolerated
2. easily digestible food (crackers, toast, cereal, banana)
pharmacological tx for acute infectious diarrhea
- self care: oral rehydration therapy, anti-peristaltics, adsorbents, probiotic
- ABX
clinical benefits of antibiotics for acute infectious diarrhea
- reduce duration of symptoms
- reduce mortality and morbidity
indications for antibiotics for acute infectious diarrhea
- severe disease (fever w bloody diarrhea, mucoid stools, severe abdominal pain, cramps, tenderness)
- sepsis
- immunocompromise
empiric therapy for acute infectious diarrhea
- ceftriaxone IV 2g q24h
- ciprofloxacin PO 500mg BD
IV to PO step down not usually necessary (unless in to out pt)
duration: 3-5d (may extend in pt w bacteremia, extra intestinal infections, immuno)
describe clostridioides difficile
- gram pos
- spore forming anerobic bacillus
- commonly causing nosocomial diarrhea
- increase duration of hospitalisation and increase healthcare cost
transmission of Clostridioides difficile
- fecal-oral route
- contaminated environmental surfaces
- hand carriage by healthcare workers
C.diff risk factors
- healthcare exposure:
- prior hospi
- duration of hospi
- nursing homes/ long term care facilities - pharmacotherapy:
- systemic exposure: number of agents and duration of tx
- high risk: clinda, FQ, 2-5th gen cephlo
- use of gastric acid suppressive therapy - patient-related:
- multiple/ severe comorbidites
- immunosuppression
- advanced age >65yo
- Hx of DCI
clinical presentation of CDI (Mild, mod,sev)
mild:
- loose stool abdominal cramps
moderate:
- fever, malaise, nausea
- abdominal cramps, distension
- leukocytosis
- hypovolemia
severe or fulminant ( 1-3% of CDI pt):
- ileus
- toxic megacolon
- pseudomembranous colitis
- perforation
- death
diagnosis of CDI
- clinical suspicion: unexplained new onset of diarrhea (>=3 unformed stool in 24h; radiologic evidence of ileus or toxic megacolon)
- confirmatory test: positive stool test result for cdiff or its toxins; histopathologic findings of pseudomembranous colitis
- culture not routinely done
types of diagnostic test for Cdiff
- nucleic acid amplification test NAAT
- toxin enzyme immunoassay EIA
- glutamate dehydrogenase GDH EIA
- PCR
when to not perform diagnosis test for CDI
- asymptomatic patients
- repeated tested <7d since most test are v specific
- test of cure, 60% remain positive despite successful tx
infection control for CDI
healthcare setting:
- pract hand hygiene
- contact precaution recommended for 48h after diarrhea resolves
- gloves + gown + wash hand w soap & water
at home:
- wash hands w soap and water after using bathroom
- use separate bathroom
- clean toilets, linens, towels, clothing with bleach
when to do empiric CDI tx
substantial delay >48h in diagnostics, or fulminant CDI
definition for non severe CDI
WBC <15 x10^9/L AND SCr <133 umol/L (1.5mg/dL)
definition for severe CDI
WBC >15 x10^9/L AND SCr >133 umol/L (1.5mg/dL)
definition of fulminant CDI
- hypotension or
- ileus or
- megacolon
tx for non severe CDI
first line:
- vanco 125mg PO QDS
- fidaxomicin 200mg PO BD
alternative:
- metronidazole 400mg PO TDS
tx for severe CDI
- vanco 125mg PO QDS
- fidaxomicin 200mg PO BD
tx for fulminant CDI
- metronidazole 500mg IV q8h +
- vanco 500mg PO QDS
+- vanco 500mg PR QDS (if ileus)
using fidaxomin for tx for CDI
- narrow spectrum macrocyclic
- inhibit transcription and protein synthesis by binding to RNA polymerase
- against gram +ve aerobes and anaerobes
benefit of fidaxomicin as tx for CDI
- lower MIC
- significant post -antibiotic effect (5.5 to 12.5h)
- less effect on normal bacteriodes spp in gut
- may reduce recurrence
limits of fidaxomin as tx of CDI
- v expensive ~2k for 10d tx
2. limited to severe and or recurrent cases non-responsive to maximal standard therapy
tx of second episodic CDI
- vanco 125 PO QDS x 10d (if previously use metro)
- fidaxomicin 200mg PO BD x 10d
- vanco PO 125mg QDS taper down
tx of third episodic CDI
- fidaxomicin 200mg PO BD x 10d
- vanco 125mg PO taper
- vanco 125mg PO QDS + rifaximin 300mg PO TDS x 20d
- fecal microbiota transplant
clinical improvement of CDI
- usually improve in 5-7d
- dont continue CDI tx for concurrent Abx
- no evidence of decrease recurrence for tx >10-14d
role of probiotics
- maintain/ restore healhy gut flora
- not recommended for routine use to prevent or treat CDI
role of anti-motility agents
- symptomatic relief for diarrhea by inhibiting contraction of intestinal smooth muscle
- limited in infectious diarrhea: reduces bowel output, affect ability to perform stool testing
- eg. loperamide, diphenoxylate, atropine
